“There are enormous differences between professionally-directed treatment institutions and mutual aid societies, just as there are enormous differences in what constitutes “treatment” and what constitutes “recovery”. A corollary of the proclamation that recovery is a reality is the recognition that professionally-directed treatment may or may not be a factor in such recoveries and, where treatment does play a role, it is an important but quite time-proscribed part of the larger, more complex, and more enduring process of recovery. Treatment was birthed as an adjunct to recovery, but, as treatment grew in size and status, it defined recovery as an adjunct of itself.
The original perspective needs to be re-captured. Treatment institutions need to once again become servants of the larger recovery process and the community in which that recovery is nested and sustained. Treatment is best considered, not as the first line of response to addiction, but a final safety net to help heal the community’s most incapacitated members. The first avenue for problem resolution should be structures that are natural, local, no-hierarchical and non-commercialised”
- William White, 2000, p.10
As often when I think I have come across a new perspective or phenomenon, I discover that the incredible William White has already reflected on it and written about it with his usual eloquence. In this case, the 2000 paper, “Toward a new recovery advocacy movement” clearly encapsulates the challenges of running treatment and recovery together under a single umbrella. The source of my unease was attending a regional event in the North-East of England on the 7th of September where a lot of agencies were labelled as ‘treatment and recovery services’, and in this article I am going to point out some of the underlying and philosophical challenges with enacting such a model.
The key point I want to make is that recovery has fundamental philosophical differences from an acute clinical care model that the two things simply cannot be run together. My own take on the key ways that recovery approaches differ from treatment approaches are:
1. Recovery support is an equal partnership in which there are evidenced methods but there is a requirement that the ‘expert-patient’ model (with its incumbent power differentials) is sacrificed in favour of a relational assumption of equality, where there can be no hiding behind professional roles and qualifications.
2. Recovery models are strengths-based and are about existential growth and meaning. The underlying assumption (and so assessment and review process) is about identifying, ameliorating or eliminating deficits. In other words, this is a zero sum game. When all of these identified harms and pathologies have been eliminated, the person is recovered. But that is not the assumption of a recovery model, which is predicated on an assumption of growth, meaning and transcendence – moving towards not moving away from.
3. From clinic to community: In the world of treatments and therapies, the clinic with its equipment and therapeutic ambience, is the location for the key activities – Orange Guidelines and evidence-based practices, contingency management and dose titration schedules. Yet it is the much more chaotic world of families, and houses, and jobs and transitioning from old friends to new that is at the heart of the recovery process and experience. Recovery is fundamentally about what goes on ‘out there’ and not ‘in here’
4. From the individual to the social and the societal: Linked to the above, the assumption in a clinical model is that addiction is a ‘biopsychosocial’ chronic relapsing condition, with the emphasis primarily on physical and psychological interventions (such as MAT and CBT). Yet the evidence around recovery is clear – recovery does not happen inside bodies, or even inside heads – it happens between people. Recovery is intrinsically a social process that is itself located within the context, culture and the environment in which the person attempts this journey. The CHIME model (Leamy et al, 2011) starts with the fundamental assumption of human connection and the concept of recovery capital is predicated on social capital as being at the heart of the process (Best, 2019). Treatment is something implemented through expert practitioners to generate ameliorative change; recovery is a shared process of mutual learning, growth and connection.
5. From professional to peer-based: When Humphreys and Lembke reviewed the evidence for recovery science, they concluded that there were three areas where there was unequivocal and clear support for a recovery approach – peer-delivered interventions, 12-step mutual aid groups and recovery residences, all three of which are peer-based. We think of recovery as a social contagion that transmits through processes of social learning and social control. And while many professional treatment services do have a lived experience workforce, it is rare for them to be afforded ‘parity of esteem’ with their medical and social work colleagues in terms of contracts, training, career development and so on. Lived experience and peer-based are the heart and soul of recovery organisations, and this is something very hard to reconcile with professional services – lived experience should not be a peripheral activity in a specialist treatment setting.
6. The fallacy of replication: In the US the Substance Abuse and Mental Health Services Administration (SAMHSA) and the American Society of Addiction Medicine (ASAM) issue clinical guidelines and in the UK, the Office of Health Improvement and Disparities (OHID) does the same thing. This is based on the clinical assumption of replicability – that done well, it does not matter if you deliver Motivational Interviewing or Suboxone prescribing in Detroit or Glasgow or Kuala Lumpur. However, the development of recovery science is not based on this assumption – place, culture and people matter. There are guiding principles but they must be adapted to fit the culture, context and personalities involved. Recovery is inherently located, treatment is inherently dislocated.
What does this mean? First, it is wonderful that treatment services want to incorporate a recovery component in their practice, and all attempts at Recovery-Oriented Systems of Care and Inclusive Recovery Cities require effective synergies between specialist treatment and recovery. However, recovery can neither be ‘sprayed on’ to existing treatment exercises nor colonised (professionalized and financially exploited) as an additional function of a treatment service. Treatment programmes should be nurturing the development of indigenous recovery supports within the natural environments of those they service rather than undermining and replacing such supports. We must be extremely cautious of thinking of recovery as either aftercare or as department where lived experience peers ‘add value’ in the community. For recovery organisations to fulfil their promise, their integrity and uniqueness must be recognised and valued as an equal partner, not an added value function. As the William White articulates in the quotation that starts this blog, it is treatment that is the optional adjunct, not recovery.
References
Best, D. (2019) Pathways to desistance and recovery: The social contagion of hope. Bristol, UK: Policy Press.
Humphreys, K. and Lembke, A. (2013) ‘Recovery-oriented policy and care systems in the United Kingdom and United States’, Drug and Alcohol Review, 33(1): 13–18.
Leamy, M., Bird, V., Le Boutillier, C., Williams, J. and Slade, M. (2011) ‘A conceptual framework for personal recovery in mental health: systematic review and narrative synthesis’, British Journal of Psychiatry, 199: 445–52.
White, W. (2000). Toward a new recovery advocacy movement. Presented at Recovery Community Support Program Conference “Working Together for Recovery” (April 3-5, 2000, Arlington, Virginia). Posted at www.facesandvoicesofrecovery.org. In White, W. (2006). Let’s Go Make Some History: Chronicles of the New Addiction Recovery Advocacy Movement. Washington, D.C.: Johnson Institute and Faces and Voices of Recovery, pp. 1-35.